International students entering the graduate program are required to submit a $25 application fee and it must accompany the application for admission. This fee is not refundable.

EQUAL OPPORTUNITY-AFFIRMATIVE ACTION

Arkansas State University policy and practice strongly support the goals of equal opportunity and affirmative action in its educational programs and activities.

ASU does not discriminate on the basis of race, color, religion, age, disability, sex, or national origin in employment of faculty and staff or admission and treatment of students, and both in terms of staff and programs we are moving ahead to comply with the goals and objectives of Title VI of the Civil Rights Act of 1954, Title IX of the Educational Amendments Act of 1972, and Executive Order 11246.

Any questions regarding this should be addressed to Coordinator of Equal Opportunity and Affirmative Action at Arkansas State University, Room 205, Administration Building, telephone 870-972-3454.

PLEASE TYPE OR PRINT

If your date of birth is January 1957 or later, you are required to present written documentation of proof of measles and rubella immunization. This immunization must have been received after the first birthday and after January 1, 1968.

The applicant must request a separate, official transcript from each college and/or university attended since leaving high school to be mailed directly to the Graduate School. Student copies are not acceptable. Return this application form to The Graduate School, Arkansas State University, Box 60, State University, Arkansas 72467.

1. NAME (print) _________________________________________________________________________________ 2. SEX (  )Male

                (Last)                     (First)                   (Middle)                            (  )Female

3. LIST ANY OTHER NAMES USED ON EDUCATIONAL RECORDS _______________________________________________________________

4. PERMANENT MAILING ADDRESS ______________________________________________________________ Phone___________________

                              (No. & St. or P.O. Box)   (City)    (County)    (State)  (Zip)

5. CAMPUS OR LOCAL ADDRESS   ______________________________________________________________ Phone___________________

                              (No. & St. or P.O. Box)   (City)    (County)    (State)  (Zip)

6. DATE OF BIRTH ____________________ BIRTHPLACE_____________________    7. RESIDENCE (  ) Resident of Arkansas

                 (Month) (Day) (Year)             (City)   (State)                      (  ) Not a resident of Arkansas

8. NAME OF HIGH SCHOOL _______________________________________________              Country of Citizenship_______________

   Address of High School _______________________________________ Date of Graduation __________________

9. WHEN DO YOU PLAN TO ENROLL IN THE ASU GRADUATE SCHOOL?

                                      (  ) Fall, 19___  (  ) Spring, 19___  (  ) 1st Summer, 19___ (  ) 2nd Summer, 19___

10. GRADUATE DEGREE YOU PLAN TO PURSUE           11. RACIAL/ETHNIC INFORMATION  (  ) White, Non-Hispanic (  ) Hispanic

    Degree____________________________________       (  ) Black, Non-Hispanic    (  ) Other (Specify) __________

    Major_____________________________________       (  ) American Indian or Alaskan Native (  ) Asian or Pacific Islander

12. DO YOU POSSESS A FULL TEACHING CERTIFICATE?  (  ) Yes   (  ) No   If yes, specify level and field.

______________________________________________________________________________________ Completed NTE?  (  ) Yes  (  ) No

13. HAVE YOU SERVED IN THE ARMED FORCES?  (  ) Yes  (  ) No 

14. HAVE YOU EVER BEEN CONVICTED OF A FELONY OR ARE THERE ANY FELONY CRIMINAL CHARGES NOW PENDING AGAINST YOU?  (  ) Yes  (  ) No 

									Semester

15. LIST ALL COLLEGES OR UNIVERSITIES ATTENDED SINCE LEAVING HIGH SCHOOL         Hours Attempted

            Name of School                     Dates of Attendance        Undergraduate     Graduate   Degree Received

  Undergraduate Major_______________________ Minor_________________________ Graduate Major __________________________

16. WORK EXPERIENCE (begin with current position   Current Office Telephone __________________________________________

   Place___________________________________________________ Position ______________________________ From 19___to 19____

   Place___________________________________________________ Position ______________________________ From 19___to 19____

   Place___________________________________________________ Position ______________________________ From 19___to 19____

CERTIFICATION (must be signed and dated before application can be processed)

I hereby affirm that all information supplied on these blanks is complete and accurate. It is my understanding that I shall not be considered for admission to Arkansas State University until I have submitted all credentials specified. Conditional admission may be given by the Dean of the Graduate School, but I understand that withholding information requested, giving false information, or not meeting all admission requirements, may result in an administrative withdrawal from the Graduate School.

Date___________________________, 19___________ Signed _________                      ___________________